Bipolar, Your Body Clock, and Finding the Best Sleep Schedule

Are you a night owl or a morning lark? Here’s what you need to know about chronotypes, circadian rhythms, and how to most effectively manage sleep patterns with bipolar disorder.

Cass has always been in love with sleep.

“I can easily snooze until 11 a.m. or noon,” says Cass of Virginia. “I’m always ready for a nap.”

Unfortunately, waking up for school or work has always been a “huge task,” she says. A proverbial night owl, Cass is most alert in the late afternoon and early evening. When left to her own devices, she tends to fall asleep around 2 a.m.

So how does she meet the demands of the real world? With difficulty.

“I have held 9-5 jobs and I would be beyond exhausted in the mornings,” says Cass, whose bipolar 1 was diagnosed at age 19. “I would often take five-hour energy drinks to stay awake, but they made me jittery and my anxiety beyond agitated.”

When she got a new job as an administrative assistant, Cass made a plan to adapt to business hours. Step 1: Go to bed no later than 10 p.m. every night — without her cell phone or tablet.

“I used to think [they] helped me fall asleep, but now I know the light can keep you more stimulated,” she says.

When she has trouble falling asleep, Cass listens to a guided meditation or plays calming music.

As for getting to work on time, her partner promised to wake her every morning.

“It’s feet off the bed, getting up, and moving around,” Cass says. “I definitely need a cup of coffee, but I now avoid energy drinks.”

The Body’s Circadian Clock

Night owls like Cass make up one of three broad categories of natural sleep patterns. These chronotypes (from the Greek word for time) appear to be genetically coded, although there are fluctuations according to age.

According to chronobiologist Michael Smolensky, PhD, coauthor of The Body Clock Guide to Better Health, around 20 percent of adults can be classed as owls.

A far smaller sliver qualify as larks — up before the sun and positively perky early in the day, but apt to lose steam by evening. Everyone else falls into a more flexible group labeled hummingbirds.

Chronotypes reflect the workings of the body’s internal clock, which is a complex biological system involving skin cells, the gut, and, of course, the brain. These operate together in our daily patterns of waking and sleeping, hunger and thirst, alertness and fatigue — otherwise known as circadian rhythms.

A heap of evidence going back decades connects disruptions in circadian processes to bipolar mood shifts. In 2010, Italian neuroscientist Francesco Benedetti told Scientific American that, “Every time we investigate some [abnormality] of molecular machinery linked to the clock genes, we find an association with bipolar disorder.”

Harry Pantazopoulos, PhD, led a research team at McLean Hospital’s Translational Neuroscience Laboratory that pursued one hypothesis: People with bipolar show a sharp decrease of a protein called somatostatin in the early morning — contrary to the more typical pattern of increased somatostatin expression at that time of day.

Somatostatin regulates a number of hormones throughout the body, but it also acts in the amygdala, which is the brain’s primitive seat of emotional response. In a very small preliminary study published in the journal Biological Psychiatry in March 2017, Dr. Pantazopoulos and his colleagues reported that, compared to a control group, there were fewer somatostatin-expressing neurons in the amygdalas of people with bipolar disorder.

Bipolar Disorder, Sleep, and Genetics

Overall, individuals with bipolar tend to have more changes in their sleep patterns in the course of a week than people with no mood disorder. The human circadian system cannot easily tolerate these abrupt shifts, says Pantazopoulos. 

An international team of researchers that conducted an extensive study of families with a history of bipolar noted that disturbances in sleep and circadian rhythms “are central features of bipolar disorder, often persisting between episodes.”

The team analyzed sleep-wake and energy patterns of more than 500 members of 26 families over three years. They reported their findings in the February 2016 issue of the Proceedings of the National Academy of Sciences.

On average, those with bipolar 1 woke later, slept longer, had greater variations in their sleep-wake cycles, and had lower activity levels while awake — irrespective of mood state — than relatives without a diagnosis.

In analyzing genetic variants related to those behaviors, the team identified 13 characteristics that were strongly tied to bipolar 1. Such insights into circadian rhythm processes in bipolar may open the door to better prevention and treatments.

“We know bipolar 1 is strongly heritable in these families,” says co-author Joseph Takahashi, PhD, who runs a lab at the University of Texas Southwestern Medical Center focused on the molecular and genetic bases of circadian rhythms. “If we can find a biological understanding of why this may be happening, we can treat it.”

Establishing Sleep Patterns That Match Your Body’s Clock

Circadian rhythms are directed by a “master timekeeper” called the suprachiasmatic nucleus, which is located just above the optic nerves in the brain and is extremely responsive to light cues.

Anything that messes with the timekeeper can trigger mood symptoms — staying up too late, crossing time zones, Daylight Saving Time (whether “falling back” or “springing forward”), changes in day length as the seasons turn.

Interpersonal and social rhythm therapy, which was developed as a psychotherapy for bipolar, aims to regularize circadian rhythms by emphasizing structure in daily routines, including when you go to bed and when you get up, when you have meals, when you work, even what time you exercise every day.

Your underlying chronotype may complicate the issue, however, especially if your body clock is out of sync with social norms.

People who exhibit “advanced sleep” — wide awake around 4 a.m. but nodding off by 9 p.m. — may do fine with the regular workday routine. 

Phil S. of Iowa City, Iowa, actually finds that 5 a.m. is the lonely hour. That’s when he regularly greets the day, but he’s learned not to send any emails before other folks are stirring.

“People get suspicious — they wonder where I’m at in my bipolar cycle, whether I slept at all,” says Phil. 

“Going back to sleep has never been an option,” he adds. “I’ve tried deep breathing and progressive body relaxation and it doesn’t calm my heart rate.”

Those techniques don’t work reliably at bedtime, either, which can vary from 9 p.m. to midnight. Explains Phil, “The more wired I am, the harder it is to go to sleep.”

If necessary, he takes something to help him sleep, though that may leave him feeling groggy in the morning.

According to psychiatrist and sleep expert Atul Khullar, MD, “delayed sleep disorder is fairly common in people with bipolar disorder.” However, he points out that certain medications have a sedating effect that may contribute to oversleeping in the morning.

One solution would be to ask your prescribing physician if taking your meds at a different time of day would help. You might also discuss the possibility of switching prescriptions to find something that doesn’t affect your sleep as much.

“There are more less-sedating options for bipolar treatment now than there were 10 years ago,” says Dr. Khullar, an associate clinical professor of psychiatry at the University of Alberta.

If you have trouble waking up refreshed and ready for the morning’s activities, it’s also important to consider whether underlying medical conditions may be at work. For example, Khullar suggests being tested for sleep apnea, a sleep disorder in which breathing repeatedly stops and starts.

“It can mimic depression and fatigue and exacerbate feelings of tiredness,” he says.

Healthy Habits to Improve Sleep 

For Wendy of San Diego, a stretch of bipolar depression in her thirties led to sleeping 12 to 14 hours a day.

“Typically, I’d go to bed at 8 [p.m.] and wake up at 8 or 10 a.m.,” recalls Wendy, who until then was more familiar with the hyped-up energy of mania. “It was difficult because I had a job as a writing tutor at a community college and I had to be there at 10 a.m.

“There were days when I just couldn’t get out of bed. I used to call in sick a lot.”

Wendy turned to a sleep specialist for help. One of the first things the doctor asked her was whether she exercised.

“She was aghast I did no exercise,” Wendy recalls. “I like to dance, so I started doing aerobics on my own to fast-paced music that I love. I stopped having so much fatigue.”

Wendy gives her exercise program a lot of credit for returning her sleep to a more normal mode, but she made other important changes as well. She no longer smokes or drinks alcohol. And she began seeing a new psychiatrist, who adjusted her medications.

She gets to bed every night at 9 p.m. and rises at 6 a.m. Once in bed, she dims the lights and reads a calming book. At 7 every morning, she meets a friend to go walking. That helps her get up, because she doesn’t want to let him down. Then she goes to work.

“Routine is so important for me,” she says. “It’s all about keeping a steady rhythm in my day.

“I’m like the most boring person alive now,” she jokes. “I try not to mess with my body clock because it will mess up my whole life.”

UPDATED: Originally printed as “A Field Guide to 40 Winks,” Fall 2016

Editorial Sources and Fact-Checking

Pantazopoulos H, Wiseman J, Markota M, et al. Decreased Numbers of Somatostatin-Expressing Neurons in the Amygdala of Subjects With Bipolar Disorder or Schizophrenia: Relationship to Circadian Rhythms. Biological Psychiatry. March 2017.